Provider Demographics
NPI:1912219288
Name:MACDERMOTT, JENNIFER RENEE (MS, RN, ACNS-BC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENEE
Last Name:MACDERMOTT
Suffix:
Gender:F
Credentials:MS, RN, ACNS-BC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-5015
Practice Address - Fax:208-381-1873
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.12917363LA2200X
ID60641363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0194314Medicaid
OHH537680Medicare PIN